(a) Period(s) of active duty (if same as above, write “same” ):
(b) Amount of wages for period(s) shown below:
Period |
Amount (amount of basic pay) |
|
|
If the amount of wage is not available, please provide:
(c) Indidivual's rank or pay grade during (this)(each) period and the date of rank:
(d) Number of years of service completed for pay purposes (longevity) for (this)
(each)period):
Date |
Signature: |
|
Title: |
|
(State Adjutant General or Authorized Representative) |